Whose Blood is Redder?

A Halakhic Analysis of Issues

Related to Separation of Conjoined Twins

Elana Perlow

hat could be more important than the immeasurable

value of a single life? Can prolonging one life at the
expense of another be justifiable? Unfortunately, for
some cases of conjoined twins, these questions demand life and
death decisions as precious time runs out and the babies lives
rest in the balance. Although conjoined sets of twins are rare, the
complex issues involved in such cases cause many concerns within
Jewish law in addition to weighty medical and ethical dilemmas.

idol worship, immoral relations, and murder, the Talmud in both

Yoma 82b and Sanhedrin 74a examines a case in which a man
approaches Rabbah for advice. The mans life was threatened if
he would not kill a specific person. Rabbah tells him that he must
sacrifice his life and not kill, for he does not know whose blood
is redder. From this it can be derived that a person cannot take
an innocent life, even at the expense of ones own life, for it is not
mans role to determine who will live and who will die.

There are two types of twins: fraternal and identical. Fraternal

twins, also known as dizygotic twins, result from the fertilization of
two eggs by two sperm. Identical, or monozygotic, twins are formed
from the fission of a zygote resulting in two genetically identical
individuals. Conjoined twins are a type of monozygotic twins
whose origins are scientifically debated. One commonly accepted
theory proposes that conjoined twins arise from the incomplete
fission of the zygote, resulting in two individuals who are physically
attached to each other. According to a second hypothesis, after the
zygote undergoes fission, the stem cells from one embryo seek out
similar cells in the second embryo and re-fuse [1].

However, the Torah states two exceptions to the above rule that
are analogous to the case of separating conjoined twins. The first
exception is the case of a rodef, a pursuer. The Torah says, Do not
stand idly by the blood of your neighbor (Leviticus 19:16). From
this, the Mishna (Sanhedrin 8:7) elaborates that if one person is
pursuing another, the rodef should be killed in order to protect the
pursued. These laws also apply in a case of unintentional pursuit
by the rodef, as illustrated in Ohalot 7:6. This Mishna discusses a
situation in which a mothers life is threatened while in childbirth.
If the baby is still in utero, the mothers life takes precedence over
the infants. The Mishna explains that the fetus is considered an
unintentional rodef and should therefore be sacrificed to save the
mother. However, the Mishna continues to say that, if the babys
head has emerged, the newborn cannot be sacrificed to save the
mother because the baby is now an independent being.

Conjoined twins may be attached at the head, chest, back, or

pelvis. In many cases, these twins can be successfully separated by
surgery and go on to lead normal lives. In the case of thoracopagus
conjoined twins, who are joined at the heart and liver, separation is
necessary but has dire consequences. In other cases, surgery is not a
viable option because the twins share vital organs.
In 1977, in Lakewood, New Jersey, a set of thoracopagus conjoined
twins was born to a prestigious rabbinic family. The sisters were
joined in the frontal area from the shoulder to the pelvic region.
They shared one six-chambered heart, composed of a stunted twochambered heart fused to a normal four-chambered heart. The wall
separating the four-chambered heart from the two-chambered heart
was too thin to divide between the twins. Even if this wall had been
thick enough to allow for surgical separation, the two-chambered
heart would not have been able to support the infants life. The
twins surgeon, Dr. Everett Koop, informed the family that if they
were not separated, both twins would die. However, if the twins
were separated, only the stronger twin would live at the expense of
the weaker twin [2,3]. From a medical standpoint it was clear that
the babies needed to be separated. However, according to Jewish
law, many questions were raised. Taking a life is no simple matter.
Accordingly, there must be a valid halakhic reason to separate
the twins, thus ending one childs life. Without a valid reason,
performing the surgery would have been forbidden because it is
considered equivalent to killing one of the twins, despite the fact
that both babies would die if not separated from one another.
A fundamental idea in halakha is that one life may not be saved at
the expense of another. While analyzing the three cardinal sins of

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The Talmud (Sanhedrin 72b) asks why the Mishna permits one
to save the mother when the fetus is still in the womb but forbids
involvement once the babys head has emerged. It would seem that
the infant should be considered a rodef regardless of its position.
However, the Talmud explains that once the head has emerged,
Heaven, not the infant, is the rodef. As Maimonides, a medieval
Sephardic philosopher, elaborates, childbirth is tivo shel olam,
the natural course of the world. In both cases, the child not only
endangers the mothers life, but the mother also endangers the
childs life, and they could be classified as mutual pursuers [3].
In his commentary on Ketubot 33b, Rabbi Akiva Eger explains
that in a case of mutual pursuit between two individuals, a third
party should not become involved because the two lives are equally
valued. If this is the prevailing halakha, one would think that a
fetus whose head has not yet emerged cannot be sacrificed to save
its mother since each poses a threat to the other. Yet Rabbi Moshe
Feinstein explains that in a case of mutual pursuit, if one of the
individuals poses a qualitatively greater threat than the other, then
that individual is deemed the rodef and may be sacrificed to save
the life of the other [3].
Additionally, the Torah teaches that feticide, unlike homicide, is
not a capital crime. It states in Exodus 21:22, And if men strive
together, and hurt a woman with a child, so that her fruit depart,
and yet no harm follow, he shall surely be fined, according as the

womans husband shall lay upon him; and he shall pay as the judges
determine. The Rabbis deduce from this verse that feticide is
not a capital offense and demands only monetary compensation
(Chagiga 11a). In contrast, unpremeditated manslaughter cannot be
resolved by payment of a fine; one who commits such an offense
must seek asylum in a city of refuge. Prior to the emergence of its
head, the unborn child is considered a fetus, and any lethal threat
it poses to its mother is considered homicide, which is a capital
offense, and any threat the mother poses to her unborn child is
considered feticide. Once the infants head has appeared, it gains the
status of an independent human being, and killing it is considered
homicide.
Another exception to the fundamental idea that one life may not
be saved at the expense of another life is derived from Samuel II
(20:1-23). Sheva ben Bikhri led a rebellion against King David.
Yoav, Davids army general, chased after Sheva and besieged
the town in which Sheva was hiding. Yoav declared that if the
townspeople handed Sheva over, the siege would end, and innocent
civilians would not be harmed. Upon hearing Yoavs proposal,
a townswoman threw Sheva ben Bikhris head to Yoav, thus
sacrificing him to save the townspeople.
Based on this account, the Talmud Yerushalmi analyzes a parallel
case in which a caravan of Jews is surrounded by heathens
(Terumot 8:4). The heathens demand that unless the Jews in the
caravan give over one of the Jews, the entire caravan will be killed.
The Jews are prohibited from acquiescing to this request, even
if it will result in all of their deaths. In contrast, if the heathens
had demanded that a specific individual be given over, the Jews
would be allowed to obey the request in order to save their lives.
Rabbi Shimon ben Lakish clarifies that in order for the Jews to
hand over the designated individual, it must be known that the
specified person is guilty of a capital offense. Rabbi Shimon ben
Lakish derives this conclusion based on the case of Sheva. Sheva
ben Bikhri was deserving of the death penalty for rebelling against
King David, since rebellion against the king is a capital offense.
Therefore, it was permitted for Sheva to be sacrificed for the
safety of the town. Rabbi Yohanan disagrees with Rabbi Shimon
ben Lakish and states that the specified person should be handed
over, even if he was not deserving of the death penalty, because
the enemies specifically demanded that he be handed over. Rashi
expounds on Rabbi Yohanans opinion and states that if protecting
Sheva ben Bikhri would not have prolonged Shevas life and still
would have resulted in the murder of the townspeople, it would
have been permissible to deliver him to Yoav. But, if it were within
their capacity to save Sheva ben Bikhri, then the townspeople would
have been forbidden from sending him to his death. Maimonides
cites only Rabbi Shimon ben Lakishs opinion (Hilkhot Yesodei
HaTorah 5:5), but the Ran agrees with Rabbi Yohanan (Yoma 82b).
Rabbi Moshe Feinstein explains that in this case, the designated
individual will be killed whether the others deliver him into the
hands of the heathens or try to protect him [3].
Yet how could Rabbi Yohanan rule that it is permitted to shorten an
individuals life simply because he is the designated victim? Through
an analysis of Rabbi Moshe Feinsteins earlier writings, Rabbi J.
David Bleich explains that the caravan surrounded by heathens
is similar to the case of two pursuers, in which the specified

individual and those who have been requested to hand him over
represent mutual pursuers. Although it is an unintentional pursuit,
the designated victims mere existence poses a greater threat to the
overall community because he is destined to die relatively soon,
while the other individuals anticipate normal longevity [3].
Rabbi Shimon ben Lakish argues by stating that the only pursuers
are the heathens. The designated individual may only be delivered
to the heathens if he is deserving of capital punishment. If he is
not deserving of capital punishment, he is not considered a rodef,
and is seen as a victim. Rabbi Moshe Feinstein elaborates that this
individual gains the status of a rodef, even if he has not committed
a capital crime, but has committed any act that may have offended
the heathens, thereby placing the caravan in danger [3].
The situation in which a baby whose head has emerged from the
womb and is threatening his mothers life is considered a case of
mutual pursuit and is consistent with Rabbi Shimon ben Lakishs
opinion. According to Rabbi Yohanans interpretation, the mere
existence of the designated victim in the caravan poses a threat to
the others and classifies him as a rodef. The baby poses an even
greater threat than the designated individual in the caravan, because
the baby actively threatens the mothers life as it pushes through the
birth canal.
These halakhic discussions can also be applied in the case of the
thoracopagus conjoined twins in Lakewood, New Jersey. According
to the twins surgeon, Dr. Koop, it was known that if the sisters
were not separated, both would die within nine months, and if
separated, the weaker twin would surely die. The case was brought
before Rabbi Moshe Feinstein to determine if it was permitted
to perform the surgery at the expense of the weaker twins life.
He inquired if the heart belonged specifically to one sister or if it
could be shared by both. Dr. Koop responded that it was clearly
the stronger twins heart and the weaker twins life could not be
extended, even if she were to receive the heart. Therefore, Rabbi
Moshe Feinstein concluded that the weaker twin was considered to
be a treifah, an individual who has less than a year to live.
Through an analysis of Rabbi Moshe Feinsteins earlier responsa on
the Talmud Yerushalmi, Rabbi Bleich suggests that Rabbi Feinstein
thought that the situation represented one in which the conjoined
twins posed a mutual threat to one another. Mutual pursuit indicates
that surgery should not be performed because a third party should
not become involved in a case of mutual threat [3].
Although it is forbidden to take the life of a pursuer in a case of
mutual pursuit, it may be permitted to separate the twin sisters
based on Rabbi Shimon ben Lakishs opinion. While killing a treifah
is still considered murder, it is not a capital crime. Medical evidence
indicates that in cases of thoracopagus twins, the twin on the left
side of the connection has a greater chance for survival than the
twin on the right. Additionally, in the Lakewood case, the weaker,
right-sided twin had cardiovascular anomalies and was incapable of
living for longer than a few short months, regardless of whether
the surgery were to be performed [3]. In this specific case, the
weaker twins congenital anomalies deemed her a treifah. According
to Rabbi Shimon ben Lakish, although the two were mutual
aggressors, the threat posed by the treifah twin as an unintentional

31

rodef to her sister was greater because it was considered homicide-a greater offense than killing a treifah. Therefore, Rabbi Feinstein
concluded that the weaker sisters life could be sacrificed in order to
save the life of the stronger sister.
After discussing this case with his father-in-law Rabbi Moshe
Feinstein, Rabbi Moshe Tendler concludes that even according to
the Rabbi Shimon ben Lakish, the twins can be separated, for even
though there was no ruling of a beit din [Jewish court] that she
was guilty of any sin and therefore would be subjected to capital
punishment, Hashem [G-d] Himself issued such a ruling. There
was an edict from Heaven that the child could not live [2]. The
twin deemed a treifah was designated by Heaven to have a shorter
amount of time on this Earth.
According to Rabbi Yohanan, the conjoined twins could be
separated because the weaker twin had been designated for
death by her inherent biological state. In the case of Sheva ben
Bikhri, Rashi explains that he should have been delivered to the

surrounding army if his death were a certainty in order to prevent

the destruction of the entire city. Similarly, because the treifah sister
has a limited lifespan, the surgery should be performed to prevent
the death of both sisters. By extrapolation, Maimonides and Rabbi
Shimon ben Lakish would likely draw the same conclusion, albeit
through different reasoning. The twins cannot be separated even
though the weaker twin was designated because she is not guilty
of a capital crime but rather because of her status as a rodef who
poses a greater qualitative threat.
On October 11, 1977, Dr. Koop performed the first successful
surgery of separation of thoracopagus twins on these sisters.
Unfortunately, although the surgery was a success, the surviving
child contracted hepatitis B from a blood transfusion and died
forty-seven days after the surgical procedure [3]. The surgery was a
revolutionary moment not only in the medical world, but because
it also allowed for the development and application of halakha in a
new realm of science pertaining to life.

Acknowledgments:
I would like to express my sincerest gratitude to Dr. Babich for his guidance throughout the process of writing this article. I would also like to thank Rabbi
Shmuel Kurtz of Chicago for first introducing me to the complexity of this topic and for reviewing the Torah content in this manuscript. And, of course,
I would like to thank my parents for their unwavering love and support. Most importantly, thank you to Hashem for granting me the opportunity to
appreciate the tapestry of the interwoven worlds of science and Torah.
References:
[1] Spencer, R. (1992). Conjoined Twins: Theoretical Embryological Basis. Teratology. 45(6): 591-602.
[2] Tendler, M.D. (2001). So One May Live. Jewish Medical Ethic, Vol. IV, No. 1. 22-25.
[3] Bleich, J.D. (1996). Conjoined Twins. Tradition: Survey of Recent Halakhic Periodical Literature. 31:1, 92-125.

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